Africa Sees Spike in Resistance to HIV Drugs

by Ed Susman Contributing Writer, MedPage Today

Action Points

Resistance to HIV-1 drugs, especially non-nucleoside reverse transcriptase inhibitors, has become more prevalent in sub-Saharan Africa as more individuals obtain access to anti-retroviral therapy (ART).

Point out that the increasing rate of resistance in the region is a concern, but drug resistance has not yet reached the level of resistance seen in the U.S. or in Europe.

WASHINGTON -- Resistance to HIV-1 drugs has become more prevalent in sub-Saharan Africa as more individuals obtain access to anti-retroviral therapy (ART), researchers reported here.

A meta-analysis of studies conducted between 2001 and 2011 in over 26,000 patients yielded a 29% increase in HIV resistance to ART in East Africa per year since ART was rolled out (95% CI 15 to 45, P=0.0001), with an estimated prevalence of HIV-1 drug resistance at 8 years after rollout of 7.4% (95 CI 4.3 to 12.7), reported Ravindra Gupta, MBBChir, at University College London, and colleagues in Lancet.

They also reported an annual increase of 14% (95% CI 0 to 29, P=0.054) in Southern Africa and a nonsignificant increase of 3% (95% CI –0.9 to 16, P=0.618) in West and Central Africa. The paper was published at the same time as the opening of the International AIDS Conference and presented as a late-breaker poster Tuesday.

"The findings are of concern and draw attention to the need for enhanced surveillance and drug-resistance prevention efforts by national HIV treatment programs," the authors stated. While they did advocate for surveillance, Gupta's group said that changes to ART guidelines are not necessary for now.

For this study, they identified studies among cohorts in Africa, Asia and Latin America. The heterogeneity of the 16 Asians studies prevented regional analyses, Gupta explained. They scrutinized 48 studies undertaken in Africa and two in Latin America.

They attributed the rise to substantial increase in resistance to non-nucleoside reverse transcriptase inhibitors in east Africa (36% per year, P<0.0001) and southern Africa (23% per year, P=0.0049). But no increases were noted for the other drug classes in any region.

They also said that limited national infrastructure, a shortage of healthcare professionals, inconsistent supply chains, and weak enforcement of quality standards may contribute to drug resistance among HIV patients in Africa.

In an accompanying Lancet commentary, Douglas Richman, MD, from the University of California San Diego, noted that the findings were consistent with studies done in high-income countries, with the prevalence of transmitted drug resistance correlating with the duration and extent of access to ART.

He said that efforts to diminish rates of treatment failure could diminish rates of morbidity and mortality and should reduce HIV transmission, including the transmission of drug-resistant strains.

The increasing rate of resistance in the region is a concern, but drug resistance has not yet reached the level of resistance seen in the U.S. or in Europe, pointed out Joseph Perriens, MD, of the World Health Organization.

He told MedPage Today that "the report in the Lancet is in keeping with what we have observed at the WHO."

"The best way to combat HIV from becoming resistant is to make sure patients have access to the best drugs, that these drugs are delivered in combination, that supplies of the drugs are consistent so that there are no drug interruption, and make sure that patients take the drugs as prescribed," he said.

Perriens cautioned that "no one should use these findings to suggest that the continued rollout of treatment should be suspended." But he agreed that further surveillance of drug resistance, which has lagged far behind the efforts to treat HIV-infected people in Africa, should continue.

The study was funded by the Bill & Melinda Gates Foundation and the European Community' Seventh Framework Programme. One co-author is an employee of WHO. Another co-author received a grant from the the Wellcome Trust.

The authors reported no conflicts of interest.

Richman has served as a consultant for Bristol-Myers Squibb, Gilead Sciences, Merck, Monogram Biosciences, Biota, Chimerix, Tobira, and Gen-Probe.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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